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It’s an intuitive truth that makes sense to just about anyone who hears it: If you are having a procedure done, you want to go to someone who has a lot of experience doing that procedure. Now, that truth is being included in ratings by organizations like The Leapfrog Group, as well as in the suggested requirements of specialty organizations. Earlier this year, the American College of Surgeons finalized requirements for pediatric surgery and the various levels of competency required by hospitals and staff to handle specific cases (https://www.facs.org/media/press-releases/jacs/pediatric0314).

For many hospitals, having surgeons or other physicians who do procedures complete a certain number in order to demonstrate continued competence has been a part of recredentialing for a while, says Kathy Matzka, CPMSM, CPSC, a consultant from Lebanon, IL, who specializes in credentialing and staffing issues in healthcare.

Many hospitals have included a numerical standard as part of core privileging for about 20 years, she says. The problem is that templates of documents have been shared around, and the numbers have been passed about as if they were delivered from on high, rather than developed through a considerable discussion among the staff at a particular hospital, she says. And there are other facilities that have simply left the number issue blank and inserted language like "must do enough for the medical staff to make a reasonable decision about continuing privileges."

"It’s easy in a big city to say that a surgeon has to do a hundred big procedures, but in a rural area, how do you set a number?" she asks.

And if you do set a number, you have to live by what you write down on paper, complete with consequences for not meeting the threshold.

That doesn’t mean that if a physician has done 29 procedures she can’t operate in your hospital if the number is set at 30, Matzka says; it means you have to put in place policies and procedures that will allow her to otherwise prove her competence, such as having a certain number of surgeries proctored by someone who is credentialed and who works in that specialty. If there is no one at your facility who can do that, then you bring in someone from outside to do so, she says.

There is also something called transference of skills, where the skills used in one procedure might be similar enough to another to constitute equivalence and thus the numeric threshold can be met in that way, Matzka notes. "Maybe you didn’t do 30, but you did 20 and a bunch of something else that uses the same skills set." In this case, too, a thoughtful consideration by staff familiar with the kind of work done by the physician in question is vital in order to protect all parties — hospital, physician, and patient. It is done on a case-by-case basis, and when and how it is accomplished has to be included in the bylaws of the hospital under the section denoting how you recredential physicians.

While some organizations that rate physicians and hospitals are taking note of numbers, Matzka says she doubts that the Centers for Medicare & Medicaid Services — from which all accreditation requirements by organizations like The Joint Commission flow — will ever do that. "They say only that the medical staff has to assess the ability to do tasks and procedures. The Joint Commission had a FAQ at one time about core privileges that said it would be inappropriate to re-grant privileges for something that someone hasn’t done in two years. But that sentence was removed." What is important to The Joint Commission and other accreditors is that you evaluate your physicians and their ability to continue to perform well on a regular basis — every two years for surgical staff, she says.

The specifics are left to each facility, Matzka says, although some data are common in just about every hospital’s review of surgeons: surgical case review, the appropriate use of blood, appropriate use of medications, return-to-surgery rates, rates of patients sent to the intensive care unit. Each department will have indicators it evaluates. Orthopedics may want to look at the appropriateness of total joint replacements, while obstetrics may be interested in C-section and VBAC rates.

She says that while it’s easy to assume that the bigger hospitals in metropolitan areas do it best, that’s not necessarily true. "I’ve worked with some critical access facilities that do a fantastic job, while some really large hospitals just don’t. In some ways, the bigger you are, the harder it is to get a handle on what everyone is doing. If you have 1,000 physicians, it’s harder to know what’s going on. In a small rural hospital, everyone knows how everyone is doing. It may not look as good on paper, but they often have a much better knowledge of what is going on in their facilities and how their physicians are performing than a large hospital with all the data and computer analysis in the world at their disposal."

Matzka says for those small hospitals where numbers may be harder to achieve, or meaningless, the best option is to get peer recommendations for recredentialing: "The direct knowledge of the people involved when you have a small medical staff and the president is evaluating can be just as edifying as numbers. They have an intimate knowledge of the kinds of procedures and most likely if they are going well or not."

Department chairmen, medical staff evaluations, nurse input — in a small facility, you have people doing a wide array of procedures they might not do if they were in a larger facility, she says. A general surgeon may be doing colonoscopies whereas in a bigger city that would be a gastroenterologist’s job. Get a good indication of what the physician in question is doing and whether it’s being done well. Look at incident reports, Matzka says, as well as complaints. Along with the traditional data, they should give you a good idea of someone’s competence. If you don’t have someone available who understands the specialty — you have just the one cardiologist or neurologist — bring someone in from outside to judge his or her work and do a chart review.

Small hospitals shouldn’t take their requirements to recredential physicians any less seriously than a large hospital that has dozens of specialists available to them, even if finding a doctor lacking could leave them without their one cardiologist, says Paul Hofmann, DrPH, president of the Hofmann Healthcare Group, a consulting firm based in Moraga, CA.

One issue he thinks could help smaller hospitals avoid problems is to avoid the clarion call of expanded service lines. Not every hospital has to have all the bells and whistles, he says, and there may not be the volume of potential patients to justify an expansion. If you end up trying to expand into a previously unknown realm, you may find it more difficult to ensure that a physician is doing all the right things for all the right reasons.

If you haven’t looked at your recredentialing policies in a while, pull them out and have a look. Set the doctors the task of discussing any numbers included in your requirements. Look at what some of the specialty societies are saying, but understand that they offer only opinions, and they can differ, Matzka says. "Different training programs will say different things. Take all of those into consideration, but in the end, your medical staff has to determine what they can live with. They are just guidelines, not requirements."

When the medical staff come up with a number, Matzka says, they should look at the numbers for every staff member and see if it would have an impact on any of them. "I have seen it happen where they fill out some form they find online that says these are the requirements, and it says 100 major procedures in the last year. They adopt it blindly without knowing what the norm at that facility is."

When they have the number and the average production for the doctors, they need to come up with a strategy for what to do with those physicians who don’t meet the number, Matzka says. If your physicians think 50 procedures is a good number, and three of your physicians are at 49, is there an argument for lowering the threshold? What about the people who are somewhat, but not significantly below it? What are the requirements they have to meet to continue practicing? Is there another way they can demonstrate competence? "If you put it in writing, you have to live with it," she says. "It may be that when you have something like that, you do a focused professional evaluation or you may look for transference of skill. Make sure it’s something you can live with."